Hodgkin's disease. A clinical and pathologic study of 235 cases

Histologic Subclassification of Nodular Sclerosis Hodgkin's Disease

Nodular sclerosis (NS) Hodgkin's disease was pathologically subdivided by cellular composition and degree of fibrosis in a series of 49 children admitted to the Istituto Nazionale Tumori of Milan between 1967 and 1977. NS showed lymphocytic predominance (LP) in 26 cases, mixed cellularity (MC) in 16 cases, and lymphocytic depletion (LD) in 7 cases. « Early fibrosis » (EF) and « advanced fibrosis » (AF) subgroups in 28 and 21 cases, respectively, were observed. Of the cases with LP 76.9 % (20/26) presented with stages I and II disease, compared with 37.5 % (6/16) and 28.6 % (2/7) of the MC and LD subgroups, respectively. LP and EF subgroups coexisted in 12 of 28 (42.9 %) patients at stages I and II. Predominance of lymphocytes, rarity of lacunar cells, and a mild degree of fibrosis were associated with early stages of disease. This data confirms that subclassification of NS is feasible.

Nodular sclerosing Hodgkin disease: new grading predicts prognosis in intermediate and advanced stages

The prognostic value of histologic classification and single histomorphologic parameters in Hodgkin disease has been widely debated in the literature. Whereas several former studies identified single parameters to be of clinical relevance, some recent reports have doubted the prognostic value of histology using modern treatment. Grading of the largest histologic category of Hodgkin disease, nodular sclerosis (NS), has been controversially discussed concerning clinical relevance. In this study, 965 cases of NS were reviewed to assess 9 histomorphologic parameters. The histologic results were correlated with laboratory and clinical findings and with overall survival and disease-free survival. Based on these results, a new grading of the NS category was established. The new grading, based on the 3 criteria eosinophilia, lymphocyte depletion, and atypia of the Hodgkin/Reed-Sternberg cells, was a significant indicator of prognosis in intermediate and advanced stages. Patients investigated in this study represent an outstanding collection because all of them were enrolled in the prospective multicenter clinical trial of the German Hodgkin Lymphoma Study Group. All of them had been staged uniformly according to the Ann Arbor system and had received stage-adapted modern treatment according to multimodality protocols. A subtle analysis of histology could represent a possible way to identify patients with a significantly better or worse prognosis. This new grading should help to avoid overtreatment to reduce severe therapy-related side effects such as acute toxicity and chronic sequelae such as cardiopulmonary complications and secondary neoplasias.

Histopathologic grading of nodular sclerosis Hodgkin's disease. Lack of prognostic significance in 254 surgically staged patients

BACKGROUND

The cellular composition of nodular sclerosis Hodgkin's disease (NS-HD) varies greatly from patient to patient. It is unclear whether subclassifying NS-HD based on cellular composition has prognostic value, because reported studies examining this issue have shown conflicting results.

METHODS

The initial pathology slides of 254 surgically staged patients with NS-HD treated at the Joint Center for Radiation Therapy were reviewed and subclassified according to British National Lymphoma Investigation criteria. The median follow-up time was 123 months.

RESULTS

A total of 211 patients were classified NS I histology (83%), and 43 patients were classified NS II (17%). There were no differences in the distribution of NS I/NS II patients by age, number of sites of disease, B symptoms, or extent of mediastinal disease. Patients with NS II disease were more likely to be male (P = 0.001), and to have pathologic Stage I-II disease (P = 0.07). The 15-year actuarial rates of disease-free survival were 77 and 80% for NS I and NS II patients, respectively (P = not significant). The 15-year overall survival rates were 87 and 93% for NS I and NS II, respectively (P = not significant). No differences were seen between NS I and NS II patients for overall or disease free survival when analyzed separately by pathologic stage or by initial treatment. Similarly, no differences between NS I and NS II patients were seen in the large subgroup of 155 pathologic stage IA-IIA patients treated with radiation therapy alone. When other histologic parameters were analyzed separately, no differences were seen in the frequency of relapse between the groups based on extent of necrosis, atypia, fibrosis, variant atypia, variant syncytia, eosinophilia, or number of mitoses.

CONCLUSIONS

The histologic subclassification of Hodgkin's disease had no prognostic significance in this group of surgically staged, uniformly treated patients.

Hodgkin disease in patients 60 years of age or older. Histologic and clinical features of advanced-stage disease. The Cancer and Leukemia Group B

BACKGROUND

This article reviews the salient pathologic and clinical features of 171 patients with Stage III-IV disease who were 60 years of age or older who were treated on four Hodgkin disease (HD) protocols from 1969 to 1988.

METHODS

Pretherapy sections were reviewed centrally for correlation of the histologic classification with anatomic sites of involvement and survival.

RESULTS

The diagnosis of HD was confirmed in 114 (66.7%) patients. Non-Hodgkin lymphomas (NHL) and a miscellaneous non-HD group accounted for 52 (30.4%) and 5 (2.9%) of the cases. The overall median survival times of patients with Stage III-IV HD and NHL who were 60 years of age or older in the four protocols were not significantly different (1.5 versus 1.3 years, respectively; P = 0.28). There also was no significant correlation between the survival of these patients with HD and either the Rye classification, 19 specific histologic parameters, or the British National Lymphoma Investigation grading system for HDNS. In the last protocol, the 5-year survival rate of patients with HD who were 60 years of age or older was lower than that of patients 40-59 years of age or that of those younger than 40 years of age (31% versus 63% versus 79%, respectively, P < 0.0001). Patients with HD entered into the two most recent protocols showed lower incidences of involvement of cervical and iliac-inguinal-femoral lymph nodes and skin-subcutaneous tissues than the patients with NHL who were misdiagnosed as HD. Moreover, patients with Stage III-IV HD in the most recent protocol who were 60 years of age or older had lower rates of involvement of the cervical and mediastinal-hilar lymph nodes and a higher rate of involvement of the gastrointestinal tract than younger patients.

CONCLUSIONS

Patients with Stage III-IV HD and NHL who are 60 years of age or older differ with respect to the rates of involvement of specific anatomic sites but not in survival when treated with HD protocols. In contrast, patients of different age groups with Stage III-IV HD disease differ with regard to the rates of involvement of anatomic sites and survival.

Hodgkin disease, nodular sclerosis type. Implications of histologic subclassification

BACKGROUND

The prognostic significance of the cellular composition of the nodules of Hodgkin disease, nodular sclerosis type (HDNS), is controversial.

METHODS

Tumors from 79 patients with HDNS, who had a median follow-up time of 9.3 years, were studied.

RESULTS

Based on British National Lymphoma Investigation criteria, 58 cases were classified as NSI (low-grade) and 21 as NSII (high-grade). The study included 24 male and 55 female patients, aged 10-57 years (mean, 27 years), who presented with Stage I (13 patients [12A, 1B]), Stage II (45 patients [40A, 5B]), or Stage III (21 patients [16A, 5B]) disease. Fifty-three patients had no relapse, 4 died of other causes, and 49 are in complete clinical remission. Twenty-six patients had progression of disease during therapy or relapsed and 17 were successfully salvaged. Overall length of survival was significantly shorter with NSII (P = 0.0001), extensive necrosis (P = 0.0034), high stage (P = 0.0058), and B symptoms (P = 0.030). Multivariate analysis showed that grade had the strongest effect on overall survival (P = 0.0042; hazard ratio = 10.19). The 5-year survival was 100% for NSI patients and 75% for NSII patients. Only B symptoms were significantly associated with risk of relapse after initial therapy (P = 0.030). For patients who relapsed, only histologic grade predicted subsequent disease-free survival (P = 0.0023; hazard ratio = 26.5). Five-year disease-free survival after first relapse was 94% for NSI patients and 11% for NSII patients.

CONCLUSIONS

Patients with NSI disease who relapse have a more successful salvage and longer period of survival than do those with NSII disease. Histologic subclassification of HDNS appears clinically relevant, and consideration of histologic subtype may be important when planning therapy.

Histologic grade does not predict prognosis in optimally treated, advanced-stage nodular sclerosing Hodgkin's disease

Forty-two patients with advanced-stage nodular sclerosing Hodgkin's disease (NSHD) were treated uniformly with combination chemotherapy and radiation therapy at the University of Nebraska Medical Center between 1982 and 1987. The cases were subclassified into low-grade (13 cases) and high-grade (29 cases) categories using the British National Lymphoma Investigation (BNLI) histologic criteria. After a median follow-up interval of 48 months, no significant differences with regard to the complete remission rate (100% versus 90%), remission durability (85% versus 96%), or predicted 4-year actuarial survival (92% versus 86%) were observed between the two groups, respectively. It was concluded that the BNLI grading scheme for NSHD does not predict the clinical outcome of patients with advanced-stage NSHD who receive optimal therapy.

Survival in Hodgkin's disease by stage and age

Patterns of care for Hodgkin's disease in the United States were surveyed through voluntary audits of hospitals with cancer programs nonapproved and approved by the Cancer Commission of the American College of Surgeons. Four hundred and seventy-three hospitals reported 6,345 patients diagnosed immediately preceding December 31, 1975. The survival rates varied with age, being better at younger ages and worse in the elderly. By pathologic stage, the younger patients faired better than the elderly in each stage grouping. Histologic type was not a factor in this poor prognosis. Hodgkin's disease in elderly patients has a different biologic behavior than in younger patients.

Tumor cell concentration and tumor burden in relation to histopathologic subtype and other prognostic factors in early stage Hodgkin's disease. The Danish National Hodgkin Study Group

Prognostic factors were examined by multivariate analysis after a recent follow-up of the 300 patients with Hodgkin's disease pathologic stage (PS) I or II treated with radiotherapy +/- adjuvant combination chemotherapy in the prospective randomized trial of the Danish National Hodgkin Study. Initial biopsy material was classified according to the Rye histopathologic classification, the grading and subclassification proposed by the British National Lymphoma Investigation (BNLI), and tumor cell concentration in sections. Tumor cell concentration as a prognostic factor turned out to be better than the other classifications. However, if macroscopic tumor burden was taken into account both tumor cell concentration and the other histopathologic classification systems lost their prognostic significance. Significantly, however, a combination of macroscopic tumor burden and tumor cell concentration, yielding an estimate of the total tumor cell burden, was even better than the macroscopic tumor burden as a prognostic factor. In conclusion, a simple tumor cell concentration count seems to be the most useful form of histopathologic subtyping for prognostic purposes in early stage Hodgkin's disease.

Relationship of histopathologic features to survival and relapse in nodular sclerosing Hodgkin's disease. A study of 1659 patients

Nodular sclerosing (NS) Hodgkin's disease (HD) with extensive areas of lymphocyte depletion or with numerous anaplastic Hodgkin's cells, termed Grade II NS, is associated with a poor response to initial therapy, an increased relapse rate, and decreased survival when compared with other NS variants, termed Grade I NS. The histopathologic subdivision of NS HD into Grade I and Grade II is easy to perform and provides essential prognostic information that is independent of stage. Patients with Grade II NS HD may require more aggressive initial therapy if their survival is to be improved.

Hodgkin's disease: a flow cytometric study

Flow cytometry was performed on paraffin embedded tissue from 115 cases of Hodgkin's disease. Thirteen (11%) tumours were aneuploid with no significant difference between the histological subgroups. The median proliferative index was 14%, and the highest values were found in the NS2 (16.4%) and lymphocyte depleted (16.0%) subgroups. The difference in proliferative index approached significance when the NS2 subgroup was compared with the NS1 subgroup (p less than or equal to 0.11) and when the lymphocyte depleted and NS2 subgroups combined were compared with the mixed cellularity, lymphocyte predominance, and NS1 subgroups combined (p less than or equal to 0.07). There was a trend towards better survival for patients with aneuploid tumours and those cases with a proliferative index below 15%, but neither of these trends was significant.

Lymphocyte-depleted Hodgkin's disease. Clinicopathologic review of 25 patients

Clinicopathologic material from 25 patients with lymphocyte-depleted Hodgkin's disease was reviewed. The median age of the patients was 57 years. The patients had no prior diagnosis of Hodgkin's disease and were divided according to pathologic subtype of lymphocyte-depleted Hodgkin's disease: 11 diffuse fibrosis, 10 reticular, and four not otherwise specified. The clinical presentation included B symptoms of fever, weight loss, or night sweats (92 percent), subdiaphragmatic disease (88 percent), frequent marrow involvement (56 percent), and advanced-stage disease (100 percent). Four of 11 patients with diffuse fibrosis had peripheral adenopathy as compared with seven of 10 patients with the reticular subtype (p = 0.3); 10 of 11 patients with diffuse fibrosis had marrow involvement compared with two of nine patients with the reticular subtype (p = 0.006). Among patients who received chemotherapy, median survival was longer in the diffuse fibrosis subtype (nine patients, 39 months) than in the reticular subtype (10 patients, 10 months), p = 0.005. Of the 17 patients who received more than one cycle of combination chemotherapy with mechlorethiamine, vincristine, procarbazine, and prednisone, the median survival was 36 months with 11 (65 percent) complete remissions. In eight patients, disease remains in remission (12 to 127 months) with five patients surviving beyond five years. These results indicate that lymphocyte-depleted Hodgkin's disease has at least two clinicopathologic subtypes and is curable if adequate therapy can be given.

Mantel irradiation for stage I and stage II Hodgkin's disease--results of a 10 year experience

One hundred and thirty patients with Stage I and II supradiaphragmatic Hodgkin's disease treated with mantle irradiation alone at the Peter MacCallum Hospital, Melbourne between 1968-1977 were analysed retrospectively. The median followup was 7.4 years with a minimum of three years. There were 64 clinically staged (CS) and 66 pathologically staged (PS) patients. The major difference between the two groups was the transdiaphragmatic relapse which occurred in 33% of CS patients, and 7.5% in PS patients. The actuarial five year relapse free survival (RFS) was 48% for CS patients and 67% for PS patients, but the five year overall survival was 90% for both groups, reflecting the impact of salvage treatment. Avid attention must be given to radiotherapy techniques to minimise local treatment failures. High grade nodular sclerosis Hodgkin's disease is associated with poor RFS even after adjustment has been made for stage and constitutional symptoms (p less than 0.003). Further studies will be made on this group of patients who may benefit from combined modality treatment. For PS I and II patients mantle irradiation gives a five year RFS of 67%, thus offering potential for cure in these patients.

Hodgkin's disease: a clinicopathologic study of 659 cases

A large number of histologic and clinical parameters were assessed, tabulated and intercorrelated in 659 patients with Hodgkin's disease evaluated and treated at Stanford University Medical Center. Nodular sclerosis was the most common pattern (60%) and also had the best total survival, but lymphocyte predominance had the best relapse-free survival. While a number of histologic parameters showed a significant correlation with relapse-free survival, multivariate analysis showed that age, stage, and treatment were relatively more important. Of the histologic parameters, only the number of lymphocytes, fibroblasts, and amount of sclerosis remained significant after multivariate analysis. The positive correlation of sclerosis, negative correlation of the number of fibroblasts and lack of correlation of lacunar cells with relapse free survival in patients with nodular sclerosis suggested that the type of mesenchymal reaction was of prime importance in determining prognosis in that form of Hodgkin's disease. The number of lymphocytes did not independently affect prognosis in patients with nodular sclerosis but did so for the entire group. The cellular phase of nodular sclerosis was found to have an overall survival and some clinical features more akin to mixed cellularity Hodgkin's disease.

Hodgkin's disease -- analysis of fifty-three autopsy cases

Eight-eight autopsy cases originally diagnosed as Hodgkin's disease (HD) were reevaluated, and 53 cases were obtained as HD. Fifty three cases with HD were composed of 47 males and 7 females and 52 cases had an active disease. Frequencies of 4 subtypes such a lymphocytic predominant, mixed cellularity, lymphocytic depletion, and nodular sclerosis were found to be 24, 54, 14, and 6%, respectively at biopsy and 12, 38, 44, and 6%, respectively at autopsy, showing transition of subtype in HD. The manner of organ involvement, deviation of histologic figures between nodes and/or other organs, associated diseases including non-bacterial inflammation of lung, amyloidosis and secondary malignancy and differential diagnosis of HD from the confusing diseases observed in our series were described.

The Rye classification of a population based series of Hodgkin's disease patients in Western Australia

Data are presented on the incidence in Western Australia of subtypes of Hodgkin's disease which were obtained by review of all cases of the disease notified between 1960 and 1974. Observations were also made on within- and between-observer agreement on the use of the Rye classification by a group of 9 surgical pathologists, all in the day-to-day practice of pathology. Although many consensus diagnoses were made only after spirited discussion by the Group, the results suggested that general surgical pathologists can perform nearly as well as lymphoma experts. A comparison of the incidence of Hodgkin's disease and distribution of Rye subtypes in Western Australia with 4 other populations showed a similar overall incidence but appreciable variation in the relative frequency of the subtypes--mainly in the proportions of nodular sclerosing and mixed cellularity.

The treatment resistance of lymphocyte depleted Hodgkin's disease

Lymphocyte-depleted Hodgkin's Disease (LDHD) is a very aggressive form of cancer that presents at an advanced stage and for which no increase in overall survival has been demonstrated with the advent of multiple agent chemotherapy. All cases of Hodgkin's disease diagnosed in the Province of Manitoba between 1971 and 1977 were reviewed. Those cases identified as LDHD were reviewed by a single pathologist, and data was abstracted to obtain a clinical profile. Survival curves were constructed comparing the LDHD group to those with other types of Hodgkin's disease. The LDHD group was also compared with an earlier LDHD group treated with single agent chemotherapy in the 1960s. The LDHD group had a significantly shortened survival compared with the other histologies. This was just as significant when mixed cellularity Hodgkin's was compared with LDHD and matched for Stage B symptomatology. Furthermore, there was no difference in survival between the earlier LDHD groups treated with single agent chemotherapy and the later group treated with multiple agent chemotherapy.

Histology, age and sex distribution, and pathologic correlations of Hodgkin's disease: a study of 184 cases observed in Rome, Italy

The Rye classification has been applied to 184 cases of Hodgkin's disease diagnosed in one of the largest hospitals of Rome, Italy, over a period of three years. Mixed cellularity was the most common histologic type. Nodular sclerosis had an intermediate frequency, while lymphocyte predominance and lymphocyte depletion showed the lowest incidence. There was a male predominance in almost all age groups, reflecting a total male to female ratio of 1.5:1. The most frequent sites of primary involvement were cervical, supraclavicular, and axillary nodes, while mediastinal nodes were found primarily involved in a limited number of cases. Incidence, results, and anatomic distribution of lesions were evaluated in 120 untreated patients who underwent staging procedures. A correlation was found between increasing histologic malignancy and abdominal spread of the disease. The most common form of abdominal disease was the simultaneous involvement of two or more tissues, and the association most frequently observed was that of lymph nodes and the spleen. Separate infiltration of the liver was rare, while involvement of bone marrow only was never observed.

The histology of the initial relapse of Hodgkin's disease

The histology of relapsing Hodgkin's disease was compared with that of the original diagnostic biopsy in 56 patients. A criterion for inclusion in this study was relapse in an untreated site, thereby excluding all patients initially treated with chemotherapy. THose patients selected for study were initially treated with local radiotherapy, and relapsed outside the initial radiation fields. There was an impressive maintenance of the histologic appearance in the relapse biopsies: a change in histology was seen only in a small percentage of cases. The histologic relationship of so-called "cellular phase" of nodular sclerosing Hodgkin's disease to classical nodular sclerosing Hodgkin's disease was confirmed. Those patients with a relapse-free interval greater than one year more often had an epithelioid cell reaction (granulomatous reaction) in their biopsy material in contrast to those who relapsed in less than one year.

Hodgkin disease: an analysis of 128 cases

An analysis of 128 cases of Hodgkin disease seen at the Department of Pathology, All India Institute of Medical Sciences, New Delhi, during the period 1968--1974 is presented with reference to histopathological and clinical findings. A male preponderance is noted in all age groups, and this is most noticeable in children under 15 years of age. There is a predominance of cases with the histologic subtypes associated with a poor prognosis (mixed cellularity and lymphocyte depleted). Only nine cases of nodular sclerosis type were seen.

Prognostic significance of histologic subdivision of Hodgkin's disease nodular sclerosis

Sixty-seven patients with nodular sclerosis (Hodgkin's disease stages I and II) have been subclassified according to the cellular composition and the amount of fibrosis. Predominance of mature lymphocytes and rarity of Reed Sternberg cells were associated with less extensive disease at presentation and more favourable outcome. A less definite correlation to the amount of fibrosis was found.

Radiotherapy results for nodular sclerosing Hodgkin's disease after clinical staging

Certain features of nodular sclerosing Hodgkin's disease predispose toward achievement of excellent radiotherapeutic results using clinical staging rather than currently advocated surgical staging including laparatomy. These include a distinct pattern of contiguous lymphatic involvement and the infrequent dissemination of disease to extranodal sites in early stage patients. Only three of 58 consecutive Clinical Stage I-III patients initially treated with radiotherapy alone between 1965 and 1969 have died from Hodgkin's disease. The 10-year survival rates corrected for intercurrent deaths are 97%, 90%, and 86% for Stages I-IIA, IIB, and III respectively. The usual prognostic influence of "B" symptoms was not evident following extended prophylactic irradiation. Likewise, there was no discernible influence of the subtype (lymphocyte predominant, mixed cellularity, lymphocyte depletion) on survival with these nodular sclerosis patients. There was a single extension of disease to iliac nodes in 46 patients with supradiaphragmatic involvement for whom prophylactic irradiation did not extend below the aortic bifurcation, providing justification for modified total nodal irradiation. Development of extranodal dissemination was observed in only 4/58(7%) patients, indicating that adjuvant chemotherapy is not warranted or justified in the early stages of nodular sclerosing Hodgkin's disease.

Hodgkin's disease in children: clinico-roentgenologic features of the lesion in the chest

The roentgenologic features of Hodgkin's disease were studied in 105 patients under 14 years of age. The mediastinal and hilar nodes were involved in 64.7% of patients. Some consistency of extent and pattern of disease was observed in that mediastinal lymphatic lesions could be associated with cervico-supra-clavicular and retroperitoneal lesions. There was lung infiltration in 14.3% of patients and the frequency of this lesion dependent on the histological type. It was commoner in nodular sclerosis, mixed cellularity and lymphocytic depletion. Lung infiltration usually developed in continuity with the lymphatic gland lesion and only rarely in a metastasis-like form.

The staging of Hodgkin's disease in children reviewed

The accurate staging of Hodgkin's disease is of greater importance in children than in adults, because the deleterious effects of extensive radiation therapy and of prolonged multiple-agent chemotherapy are of greater significance in this age group. The physician concerned with Hodgkin's disease in children must separate those aspects of developments in this field which are applicable to the pediatric age group from the relatively large adult experience. Isotope scanning is effective in demonstrating disseminated disease in pediatric patients. Lymphangiograms are useful, but are more difficult to perform and to interpret in children. When laparotomy is performed in children with clinical Stage I, II, or III Hodgkin's disease, stage will be altered (upward or downward) in approximately 40% of children subjected to the procedure. As growth retardation, skeletal deformity, and secondary neoplasia follow radiotherapy in children, the major function of the laparotomy is to delineate the extent of the disease and thus define appropriate limitations of therapy.